Rehabilitation following Hip arthroscopy Prof. Ernest Schilders Leeds Metropolitan University...

Rehabilitation following Hip arthroscopy Prof. Ernest Schilders Leeds Metropolitan University Bradford Teaching Hospitals

Hip arthroscopy Rehab Start Which procedure? Operative Findings Return to sport? Type of sport Fitness Type of procedure Progress of the rehab Patient orientated Use assessment criteria Pain Orginal pain Procedure specific Rehab related

Questions to answer before we start our rehab program What is the exact procedure and operative findings? Faster rehab program for simple and longer for complex procedures. How long was the patient injured before his surgery? Conditioning is a very important element of the rehab.

Incidence of pathology in athletes n=120

Incidence of intraarticular pathology

Type of articular cartilage lesion

Femoroacetabular Impingement simpleDiagnostic, Removal loose body Labral debridement Ligamentum Teres debridement IntermediateCAM decompression Iliotibial band release Iliopsoas release complexAcetabular rim trimming + labral repair + CAM decompression Microfracture (prolonged crutches) Very complexAcetabular rim trimming+ labral repair+ CAM decompression + capsular plication

Procedures in athletes

Procedure specific rehab advice FAI surgery (1-4 week crutches PWB) Microfracture (prolonged use of crutches 6-8 weeks) Capsular Plication (use of night splints in internal rotation for 4 weeks)

Clinical and operative findings that might have a negative impact on the rehab Pain and a negative hip arthroscopy Presence of extensive grade 4 cartilage lesions. Generalised hyperlaxity in patients with instability symptoms. Centre edge angle below 20 degrees. Low preop outcome score.

20y old professional football player CE angle= 20 vertical sloping weightbearing surface. Perthes disease Generalized hyperlaxity

Perioperative pain management Muscle relaxant at induction (Atracurium 0,6mg/kg) Remifentanyl infusion during surgery for blood pressure control, muscle relaxation and analgesia. Multimodal analgesia at the end of the surgery. NSAID/ paracetamal and morphine. Postoperative pain relief consists of codeine, paracetamol and NSAID Antibiotics administration at induction.

Rehabilitation ladders Process whereby patient/player progresses through rehabilitation, achieving goals within specific timescales. Easy to follow. Based on evidence and agreed with consultant involved.

Other considerations Use realistic timescales (Always err on the side of caution). Use common sense, as injured patients/players will progress at different rates.

Frank Gilroy Post surgical general rehabilitation ladder Timescales depend on consultant involved Regain full ROM Increased strengthening and proprioception MEDIUM STRESS Pre-op preparation Surgery Regain ROM Early strengthening LOW STRESS Increased shearing activities, agility, sports specific rehab Advanced strengthening and proprioception HIGH STRESS

8-12 week ladder Timescales depend on consultant involved Phase 3 Straight line running, strengthening exercises, increased pool work and full stretches MEDIUM STRESS Pre-op preparation Surgery Phase 1 Gentle walking and light stretching LOW STRESS Playing again! Phase 4 Short sprints and shuttle runs, increasing core stability work. Gradual return to sports specific training HIGH STRESS Phase 2 Jogging 20-30 minutes, light stretching and pool exercises

Week 1 Ankle pumps

Week 1 Ankle pumps, Isometrics Gluteal, Quads, Trans Abs, Hip abduction

Isometrics These are static exercises. When you do the exercise you should feel the muscles tighten without movement of the joints. Try to do twenty repetitions of each exercise, 2 times a day. Gluteal sets: tighten your buttock muscles hold for 5 seconds. Quads sets: tighten the front thigh muscles hold for 5 seconds. Transversus Abdominus : Draw belly button in towards spine without moving pelvis/spine hold while taking 5 breaths. Hip abduction : Lying on your back with hip and knees bent, place a belt around your thighs near your knees and push out against the belt hold 5 seconds

Week 1 Ankle pumps, Isometrics Gluteal, Quads, Trans Abs, Hip abduction Stationary bike start 20 mins x 2 daily

Stationary Biking with high seat and minimal resistance. As soon as you are comfortable enough to get onto a bike, cycle for 20 minutes 2 times a day. Increase the time by 5 minutes after 3-4 days until you have reached a maximum of 45 minutes twice a day. No resistance should be added until week 5-6.

Week 1 Ankle pumps, Isometrics Gluteal, Quads, Trans Abs, Hip abduction Stationary bike start 20 mins x 2 daily Passive stretching, Piriformis stretch (side lying), Quads stretch (prone), Adductor stretch (sitting)

Passive stretching exercises Lying on your good side (bottom leg straight and pelvis stacked) bend your involved hip to between 50 to 70 flexion and hook top foot behind uninvolved knee. Steadying the pelvis, lower the involved knee towards bed. Stretch should be felt in buttock, avoiding a pinch in groin. Piriformis stretch

Quadriceps stretch Do 5 repetitions, hold for 20 seconds, and twice a day. Lie on your stomach with your hips flat on the bed. Ask a partner bring ankle toward buttock, feeling stretch in the front of the thigh. If it is too painful to lie on your front, you can do this stretch lying on your good side.

Adductor stretch Do 5 repetitions, hold for 20 seconds, and twice a day. Sit in a chair with the feet on the floor. Carefully move the knee of the affected leg out to the side so the hip is opening out (abducting). Do the stretch as comfort allows and feel the stretch on the inside of the thigh.

Week 1 Ankle pumps, Isometrics Gluteal, Quads, Trans Abs, Hip abduction Stationary bike start 20 mins x 2 daily Passive stretching, Piriformis stretch (side lying), Quads stretch (prone), Adductor stretch (sitting) Price

Week 2 Week 1 exercises (including) Quadruped rocking

3 sets, 20 repetitions, once a day. On your hands and knees shift your body weight forward on your arms, and then back onto your legs. Also shift your weight side to side and in diagonal directions.

Week 2 Week 1 exercises (including) Quadruped rocking Standing Hip IR

Standing hip internal rotation 3 sets, 20 repetitions, once a day. Place knee of the operated leg on a chair. Rotate the hip by moving your foot outward from the body. Progress the exercise by using a resisted band when tolerated.

Internal rotation strengthening with thera bands Start positionFinishing position

Week 2 Week 1 exercises (including) Quadruped rocking Standing Hip IR Heel slides with/without strap Cons r/v

Weeks 3-4 Pain relief Price, electrotherapy or mobilisation Gait re-education ROM exercises (Cont week 1 & 2 exercises) Stretching (piriformis and quads) include Faber, calf, hamstring and ITB Gym work (if appropriate) Bike no resistance but increase time (aim to build for 45 mins x 2 daily), Leg press low weights and repetitions, Cross trainer min resistance monitor time, Swiss ball Core stability Hydrotherapy

Faber lying on your back bring involved leg into a figure four position with the ankle resting above the opposite knee. Gently lower the bent knee towards the floor. You may need to start with ankle resting on the shin or inside of the leg. It is normal to feel some hip discomfort underneath the thigh. DO NOT PUSH ON THE KNEE.

Weeks 3-4 Pain relief Price, electrotherapy or mobilisation Gait re-education ROM exercises (Cont week 1 & 2 exercises) Stretching (piriformis and quads) include Faber, calf, hamstring and ITB Gym work (if appropriate) Bike no resistance but increase time (aim to build for 45 mins x 2 daily), Leg press low weights and repetitions, Cross trainer min resistance monitor time, Swiss ball Core stability Hydrotherapy

Weeks 5-6 Cont weeks 1-2 and 3-4 (include the follwing) Gym work within capabilities ( inc resistance on bike alter time) Balance work wobble board, trampette Core stability progress as able HEP lunges, lateral side steps, knee bends, fartlek (jog/walk)

Weeks 7+ Week 1-2 exercises can be stopped Cont with weeks 3-4 and 5-6 Increase hydrotherapy exercises (squats, step ups/downs, - lunges. Running progress from straight line to multi-directional Sports specific

Advanced hydrotherapy

Advanced hydrotherapie

Which questions do we have to ask ourselves? How do we know that our rehab is progressing steadily, what is normal and what is abnormal? What are the standards we can realistically aim for? (measurements of outcomes) Can we separate the built up of fitness from a hip arthroscopy specific rehab program?

Which assessment criteria can we use during rehab? Pain Functional scores Modified Harris Hip Score Hip outcome osteoarthritis score (HOOS) SF 36 Subjective assessment? Objective Static information Range of motion Strength test Log roll test Objective dynamic evaluation SPORTS TEST

Pain following the procedure Procedure related Adhesions, microfracture, labral repair, decompression CAM or pincer. INFECTION Traction related adductor pain Pectineus Sciatic pain Ankle pain Rehab related Iliotibial band and trochanteric bursitis Psoas Hip flexors Synovitis Sacro iliac joint pain.

Pain and Stiffness Pain: Reintroduce analgesia, NSAID rarely steroid injection. Limited rest Concentrate on Deep Rotators of the hip. Stiffness: ROM stuck (very rarely) ; check X rays or CT scan to investigate for residual impingement

Risk factors for adhesions More complex arthroscopic procedures. Pre-operative sensations of stiffness that limits function. Possible risk factors Longer time on crutches Grade 4 articular cartilage lesions treated with microfracture.

Iliotibial band Compression of the trochanteric bursa due to iliotibial band tightness. *Weakness of the hip abductors causing increased hip adduction. *Swelling bursa due to fluid extravasation. *swelling and insufficiency muscles due to portal trauma. Osteopathic technique to reduce the tightness, myofascial release. counterstrain a positional release technique.

Research in progress, Iliotibial band tightness Weakness of the hip abductors and imbalance between adductor/abductor strength. Reduced hip mobility compared to controlateral side an issue to address early in the rehab, before athletes have increased their activities to significantly

Which assessment criteria can we use during rehab? Pain Functional scores Modified Harris Hip Score Hip outcome osteoarthritis score (HOOS) SF 36 Subjective assessment? Objective Static information Range of motion Strength test Log roll test Objective dynamic evaluation SPORTS TEST

Modified Harris Hip score Preoperatively39-96 2 months postop58-100 6 months postop74-100 Minimum of 12 months postop.70-100

Overall the average pre-op MHHS was 62.1 (95% CI 57.8-66.4) and the average post-op MHHS, after minimum 1 year, had statistically significantly increased to 94.8 (95% CI 92.8-96.9) (p

Sports test M Philippon Scoring criteriasubsets Time20-30 seconds Endurance Form Pain Total1 point Passed > or = 17 points Failed < 17 points

Timing to sport Difficult to predict. Should be athlete orientated rather the rehab orientated. Need for objective measurements before allowing athletes to go back to sports.

Risk factors for reinjury History of injuries and low level of off-season sport specific training. Consider the time an athlete has been out with an injury, before having surgery.

Risks of early return Persistent Pain Prolonged rehabilitation time. Low performance Re-Injury( new labral tear, articular cartilage lesion) New Injuries. Emery et al. Med SciSports Exerc, 2001.

When would I stop an athlete from returning? Lack of endurance in sports specific tasks. Pain in sports specific positions. Progressive adaptations can be feasible. Dressage: start with small horses before wide horse, stirrups higher, to sit in a flexed more abducted position.

Endurance muscles fibers are the first to be lost after hip surgery and take longer to recover. Suaetta et al. J ApplPhysiol, 2008. Deschenes et al. Am J Physiol, 2002. Ferrettiet al. J ApplPhysiol, 2001

Principles If possible see patient/player pre-operatively to prepare joint involved, and explain process and timescales involved. Always work closely with the surgeon involved. Whenever possible follow evidence based guidelines.

Return to sports following impingement surgery Soccer2-4 month Rugby2-3 month Basket ball5 month Hockey3-4 month Dance 3 month Martial arts3 month Tennis2 month sports involving twisting and turning

Return to sports following impingement surgery Golf2-3month Cycling6week-2 month Running2 month Rowing2 month Rockclimbing3 month Sports not involving twisting and turning

Hip arthroscopy Rehab Start Which procedure? Operative Findings Return to sport? Type of sport Fitness Type of procedure Progress of the rehab Patient orientated Use assessment criteria Pain Orginal pain Procedure specific Rehab related

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Rehabilitation following Hip arthroscopy Prof. Ernest Schilders Leeds Metropolitan University...

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